On day one of physical therapy school, I heard the words “if it’s not documented, then it didn’t happen.” Throughout my career, I have heard this time and time again and used this when I was a Home Health Administrator, SNF Therapy Coordinator, and Outpatient Therapy Coordinator. This quote is constant throughout the health care profession to promote timely and accurate documentation of clinical care, coordination of care, and the protection of health care professionals from legal allegations. Point of service documentation is more important than ever. Health care has evolved from paper documents to electronic records with a heightened focus on patient – centered care. Patient – centered care and reimbursement are tracked by data collected through documentation by the health care professional. Are you utilizing point of service documentation and if you aren’t – how accurate is your documentation?
When utilizing our long-term memory, which is any information that occurred a few moments ago, false memories can be triggered. This can be contributed to how the memory was initially stored, if you were fully engaged in the event, and your alertness. People do miss important details about events and to fill in these missing “gaps” of information, the brain can fabricate details that seemed to occur. This makes it difficult to recall what truly occurred due to old memories interfering with the formation of new memories.
The stresses placed on health care professionals continues to rise, as reimbursement decreases, and more emphasis is placed on high productivity standards and data driven indicators. High efficiency standards coupled with fast-paced work environments are susceptible areas to developing false memories leading to inaccurate documentation. Providing detailed and accurate documentation is a requirement of all health care professionals. We all need to be held accountable for providing point of service documentation unless a situation truly doesn’t allow for it, and in this case, the documentation should be completed immediately following the specific intervention or treatment session. We will be able to recall the information stored in our long-term memory with less potential for false memories to occur. This also allows us to review the information being documented with our patients to promote patient and/or caregiver involvement in the progression of care.
When performing compliance audits and documentation reviews, I have identified common trends that occur with health care documentation. A few of these common trends are:
- Documentation cloning (pre-fabricated statements that aren’t patient specific and occur repeatedly throughout the patient’s medical record)
- Duplication of services (performing services in your scope of practice with goals varying from other disciplines)
- Lack of medical necessity or justification of services
- Incorrect ICD 10 coding for both medical and treatment diagnosis, and re-certifications or progress notes out of the permitted range.
These common trends can be avoided with point of service documentation and reviewing the patient’s plan of care with the patient and/or patient representative every treatment session.
Providing accurate documentation that is completed during treatment or immediately following treatment (when point of service documentation isn’t appropriate) is significantly important to the patient’s plan of care, coordination of care, reimbursement, and protection from lawsuits. The old saying of “if you didn’t document it, then it didn’t happen” is correct, but this doesn’t state when it should be documented. Health care is constantly evolving and our documentation expectations should be held to the same standards. My new quote is “document it as it’s happening, or it didn’t happen.”